Rheumatism and Gout

larly at the outset, a dose of blue pill, followed by Carlsbad salts, is to be recommended. In chronic gout, galvanism, preceded and followed by massage, often brings about a rapid reduction in size of the joints, and unless the disease is of very longstanding, radiant heat baths often start a steady improvement which goes on long after they cease to be given. Cataphoresis is also useful, the bicarbonate of potash being applied on a pad to the joint under the positive pole, with about 20 milleamperes of current. For prophylaxis 10 grains of guiacum resin may be given three times

gout, galvanism, preceded and followed by massage, often brings about a rapid reduction in size of the joints, and unless the disease is of very longstanding, radiant heat baths often start a steady improvement which goes on long after they cease to be given.
Cataphoresis is also useful, the bicarbonate of potash being applied on a pad to the joint under the positive pole, with about 20 milleamperes of current.
For prophylaxis 10 grains of guiacum resin may be given three times a day in a capsule.Toogood23 notes the importance for diagnosis of the first appearance of the disease in the great toe, while the incidence of subsequent attacks is largely influenced by " occu-pation strains " in any joint.The flexion of ^ distal phalanx and the over-extension of ^ ^ central one of the middle finger is also typlC Luff24 speaks strongly on the injury done j mistaking rheumatoid arthritis for gout, and ) giving a poor diet, which is ruinous in the disease.He believes strongly in guiacol for rh matoid arthritis, and says that if enough is glV ^ and for a sufficient period, it will generally arre1v the disease.Indeed, the disease if taken ear ? is curable.He gives the almost tasteless carp0 ate of guiacol in doses up to 20 grains three tun daily in cachets for at least a year.v writers, however, find no difficulty in giving 1 ^ to 20 or even 40 drops of guiacol, or pure creoso simply beaten up in milk three times daily ^ long periods to phthisical patients, and smallest of these amounts is equal to 40 gral K of the carbonate.]He also gives iodide with n ' vomica and glycerophosphates.Douche-mass^ radiant heat, " general" electric baths, and pe baths [or boxes filled with heated salt] are helpful.The interest of investigators has t>e i to some extent transferred from uric acid a j5, the urates to the purin bodies, but A. C. Crofta^0 has carried out a series of experiments on ^ transformations of uric acid in the tissues, and finds that (1) uric acid is normally destroyed , the human body by the aid of certain " fermen ^ the muscles destroying the greatest quantity, the kidneys, then the liver, the spleen and fin3, ^ the blood; (2) since the kidneys destroy lfc, 9 themselves, the uric acid in the urine is ?? ^ measure of that in the blood, but failure ox April 9, 1904.THE HOSPITAL.27   kidney functions may lead to an excess of uric acid in the blood, i.e. renal disease may be a fore- runner of gout; (3) the frequency of liver dis- orders before attacks of gout may imply the failure of the liver to destroy the circulating uric acid or that ingested in food; (4) the value of salicylates and dilute alkalies in gouty conditions is explained by the fact that they increase the liberation of oxygen from nucleo-proteids; (5) since the kidney can form oxalic acid out of uric acid, the presence of oxaluria in gout is also ex- plicable.The experiments show, too, that uric acid is transformed into urea, and, therefore, uric acid is not a terminal product; (7) some of the organs at least which destroy uric acid also break up fats and sugars, hence when they are diseased we find together obesity, diabetes, and gout.Woods Hutchinson20 points out that uric acid is not due to the imperfect change of proteids into urea, or from an excess of nitrogenous food, but rather from the nucleins alloxurs and purins in the food and tissues.It is clear that about half is due to the food and half to the destruction of nucleins in the tissue.
The importance of uric acid, in spite of Haig and Garrod, is doubtful since it appears to be unirritating.Thus in leu- kaemia and in children it may be present in large amounts without any effects except for some mechanical disturbance when precipitated in the Urine; and it has been injected into animals and given in their food with similar results.

He
Regards the uric acid of gout like the phosphoric acid which accompanies it as the measure of the destruction of the leucocytes in response to an invasion of toxins.
Most of these toxins are of intestinal origin.Hence the diet should be regu- lated to avoid fermentation and any excess of food beyond what the body can oxidise; and since it is only the endogenous half of the uric acid "which is increased in gout, there is no reason for forbidding foods rich in purins and nucleins, such as sweetbreads.The function of the liver in gout, too, is merely negative, that is, it is unable to carry out its work as a poison filter and destroyer of toxins.
Chalmers Watson,27 too, argues that uric acid is not the primary factor in gout, and that it can be deposited in the tissues without any inflammatory reaction.
Regarding the process in gout as due to intestinal toxins, he gives a minute account of the post-mortem findings in a case of acute gout in a fowl.
Besides typical gouty changes in the tissues and synovia, he found features in the spleen and pancreas indicative of a bacterial invasion, and changes in the intestines and kidneys which pointed in the same direction.It was argued against him that the disease was really an acute nephritis, and that in birds the destruction of the kidneys leads to the accumula- tion of uric acid in the tissues, but Watson replies that the convoluted tubules were singularly healthy, and moreover uraemia does not seem to depend upon a retention of urea and similar bodies in the organism.The appearances in the tissues were certainly those of a general infectious process, and this is what he believes gout to be.
Citarin has been praised as a remedy for gout.It is produced by the action of formaldehyde on citrate of soda, and the former is known to form a very soluble compound with uric acid.Lieb- holz28 records most successful results, and advises its being given as early as possible in an acute attack as soon as the first symptoms appear, and in large doses, say 30 grains every six hours,, which can be reduced to eight hours on subse- quent days.The pain and swelling is brought to- an end very rapidly, and no ill effects have been noticed except sometimes a slight diarrhosa.